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A BWH team performs surgery at Brigham and Women's/Mass General Health Care Center in Foxborough. Inset: Atul Gawande
The first time Atul Gawande, MD, MPH, took a checklist into the Operating Room at BWH, his team rolled their eyes and, before day’s end, all had agreed to abandon the checklist because it took too long and didn’t make much sense.
Sixty revisions later, Gawande and his team at the World Health Organization had created a short, effective checklist that would be adopted by at least 1,600 hospitals worldwide, including BWH, as a way to prevent error during surgery. A pilot that was initially conducted in eight hospitals around the world revealed that using the checklist reduced complications by an average of 36 percent and death by an average of 50 percent.
“Our final checklist can be done in less than two minutes and is designed to help teams handle complexity,” said Gawande, an endocrine and general surgeon at BWH who is leading the World Health Organization’s global campaign to reduce avoidable deaths and complications in surgery. “Operations can go wrong in hundreds of ways you can’t anticipate, but the knowledge of what needs to happen is right there in the room. The team can be prepared to work together successfully.”
Gawande, whose book “The Checklist Manifesto” became a New York Times bestseller, presented at BWH Quality Rounds last month about the process for developing the surgical checklist and how it may be adapted for crisis situations and disciplines beyond surgery.
Scientific discovery has led to the knowledge of more than 13,600 different diagnoses. To treat these diagnoses, clinicians can prescribe from more than 6,000 drugs and carry out nearly 4,000 surgeries and medical procedures.
“The job of a health system or medical community in every town across the country is to deploy all of those treatments and regiments to every single person in the right way at the right time without wasting resources,” said Gawande to a packed Bornstein Amphitheater. “Guess what? It is unbelievably hard to make this always go the way we want.”
With such complex systems, procedures and diseases, a checklist is a simple way to prompt a team on steps that might fall through the cracks.
“The checklist is a natural approach,” he said. “It was the approach the military took in 1935 when Boeing designed an airplane complex enough that a pilot wasn’t going to remember every single thing he or she needed to do every single time, so they codified it.”
The team implemented the checklist in the eight hospitals participating in the pilot, adapting it each time to meet the needs of specific organizations. In Manila, for example, a medical student, rather than a nurse, was put in charge of the checklist because the hospital had one circulating nurse for four operating rooms. “We had to engage key leaders and adapt our list to work in each setting,” Gawande said.
Observing dramatically decreased deaths and complications over three months, the team published the findings in the New England Journal of Medicine, and 25 countries adopted the checklist as a national standard. Since then, Gawande’s team has studied hospitals that implemented the checklist to determine why some received buy-in from surgical staff immediately and others did not.
“A checklist is a set of values; it reflects humility and the willingness to recognize you don’t know everything, and you might forget things,” he said. “You need self-discipline to follow a process, and you need to build this around teamwork, not one person.”
They determined that, among other things, involvement of senior leadership and a history of performing quality improvement projects made some hospitals more likely to adopt the checklist quickly.
Today, Gawande’s team is creating checklists for high stress situations in the operating room and is considering whether it could benefit fields such as emergency medicine and obstetrics. Through simulation, Gawande’s team is testing the effectiveness of checklists for the 12 most common crises in operating rooms. The team also is testing safe childbirth checklists at other hospitals, including one in India beginning this summer.
“What’s most important is to identify the processes necessary for good care. Do we do them all the time?” he asked. “The answer is almost invariably no. We can make processes that change the care, and do it in a way simple enough to bring that knowledge to the point of care. By doing so, we can transform the care people receive not just here at the Brigham, but everywhere.”
Atul Gawande’s article, “The Cost Conundrum,” was honored in the public interest category as a recipient of a 2010 National Magazine Award.
Sponsored by the American Society of Magazine Editors in association with the Columbia University Graduate School of Journalism, the National Magazine Awards were established in 1966 and have long been recognized as the preeminent awards for magazine journalism in the United States. More than 300 magazines participated in the National Magazine Awards this year, submitting 1,758 entries; 51 magazines were nominated in 23 categories.
Published June 1, 2009, Gawande’s article examines health care costs and outcomes in McAllen, Texas. Gawande, who completed his surgical residency at BWH in 2003, has been a staff writer for the New Yorker since 1998.
View the “checklist for checklists” and learn how to create an effective checklist. www.ProjectCheck.org